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COPING STRATEGIES DURING CHRONIC ILLNESS The Professional Medical Journal www.theprofesional.com CASE REPORT PROF-2724 EFFICACY OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING BEYOND COMPLEX POST TRAUMATIC STRESS DISORDER: A CASE STUDY OF EMDR IN PAKISTAN Maj. Dr. Muhammad Sami Bilal1, Prof. Mowadat Hussain Rana2, Col Safi Ullah Khan3, Brig. Rashid Qayyum4 1. MBBS (Q.A.U), Dip Psych (AFPGMI), MCPS (Psychiatry), FCPS (Psychiatry) Classified Psychiatrist Head of Department of Psychiatry Combined Military Hospital, Multan 2. MBBS, Diploma in Psychiatry, MCPS, FCPS (Pak), MRC Psychiatry (London), DCPS-HPE (Pak), MCPS-HPE (Pak) Professor of Psychiatry Dean of Psychiatry, College of Physicians and Surgeons Pakistan Rawalpindi 3. Classified Health Care Administrator Deputy Commandant CMH Multan 4. Classified Psychiatrist CMH Peshawar Correspondence Address: Major Dr Muhammad Sami Bilal Classified Psychiatrist, CMH Multan. [email protected] Article received on: 29/11/2014 Accepted for publication: 26/03/2015 Received after proof reading: 17/04/2015 ABSTRACT… Objectives: To demonstrate the efficacy of EMDR in complex multiple psychological trauma after failed drug treatment from selective serotonin reuptake inhibitor (SSRI) in a diagnosed case of post-traumatic stress disorder (PTSD). Method: Single participant of this case study, a sitting session judge of judicial governmental scaffold reported to this mental health tertiary care facility at his own accord with features of intense anxiety, depression, maladjustment issues and post- traumatic stress for a duration of several months. As a partial responder to full trial of SSRI he was enrolled for EMDR therapy to address his symptoms of intense anxiety, panic attacks, being overwhelmingly fearful, depressed, low selfesteem, inappropriate feelings of guilt, flashbacks, avoidance, nightmares, hyper-arousal and inability to perform as a judicial head in active war stricken area of northern Pakistan. Complete psychiatric evaluation was carried out and after the discontinuation of SSRIs he was scored on Impact of Event Scale (IES). He fulfilled the diagnostic criteria for PTSD as evaluated by the English version of the PTSD module of the Structured Clinical Interview for DSM-IV administered once before commencement of EMDR. Safe place of the client was established and 8 staged protocol of EMDR was started with him. Multiple EMDR sessions were conducted. Result: The case presented in this paper had multiple psychological trauma forms and failed drug treatment and yet it was observed that EMDR provided marked improvement in all the domains of his deficits and this was at a prompt speed as compared to cognitive behavioural therapy (CBT) which usually takes longer duration of therapy to achieve similar results. Conclusions: EMDR provides marked improvement in all domains of complex mental trauma and traumatic memories. Improvement attained was prompt and enduring as compared to other forms of established therapies and drug treatment indicating permanent changes happening at neurobiological levels of brain. Key words: EMDR, PTSD, Tf-CBT, man-made disasters, natural disasters, psychological trauma, Pakistan, IES-R, SCID-I, CTRPI, AFIMH and ACTR. Article Citation: Bilal MS, Rana MH, Khan S, Qayyum R. Efficacy of eye movement desensitization and reprocessing beyond complex post traumatic stress disorder: a case study of EMDR in Pakistan. Professional Med J 2015;22(4):514-521. INTRODUCTION Transition from Trauma focused cognitive behavioural therapy (Tf-CBT) to EMDR Post-traumatic stress disorder (PTSD) is an anxiety disorder that is diagnosed when a person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person’s response involved intense fear, helplessness, or horror.1 There are numerous forms of psychological trauma sustained by multiple natural and manmade sources. These atrocities include incidences like domestic vehemence, physical abuse, rape, street assault, mugging or battles cause extensive Professional Med J 2015;22(4): 514-521. psychological trauma. Similarly natural disasters and calamities produce direct physical injuries as well as widespread mental trauma in individuals. An individual can be the victim of single traumatic experience or suffer from enduring adversities.2 After experiencing a traumatic event, a person may display a range of disorders, including acute stress disorder (ASD), post-traumatic stress disorder (PTSD), depression, generalized anxiety disorder, childhood traumatic grief, specific phobias, and separation anxiety.3 Among the trauma therapies, cognitive behavioral therapy (CBT) is qualified as an established treatment.4 A recent systematic review of effects of interventions for trauma symptoms revealed www.theprofesional.com 514 COPING STRATEGIES DURING CHRONIC ILLNESS that individual and group CBT was most effective.5 CBT for trauma is based on the principles of cognitive and learning theories and aims to decrease negative emotions and behaviors, and to transform dysfunctional cognitions and attributions about the traumatic event.6 Traumafocused CBT.7,8 consists of multiple components, including: trauma narrative, in vivo mastery of trauma reminders, affect modulation, cognitive processing, psycho-education, relaxation, parenting skills and enhancing safety, healthy sexuality, and future development.9 There are multiple exposure based therapies for mental traumas, yet all these therapies may not be fruitful in some individuals and this may considerably hamper treatment outcomes. Synopsis of Eye Movements Desensitization and Reprocessing (EMDR) An American psychologist Francine Shapiro is the originator of the Eye Movement Desensitization and Reprocessing (EMDR) and this therapy first came into lime light in 1989. With eight stages of protocol of EMDR, the traumatic memory is desensitized by short imaginal exposure to this memory and the subsequent offering of bilateral stimuli.10 This is repeated until the accompanying level of disturbance has disappeared and the dysfunctional cognitions about the trauma have become functional.11 Traumatic memories are expected to transform into least stress inducing memories through EMDR. The adaptive information processing (AIP) model shares features with the emotional processing model, which explains the reduction of fear in anxiety disorders.12 Thus, free association and distancing is allowed by means of the EMDR procedure; within the emotional processing model free association is generally not allowed.13,14,15 With EMDR a three-pronged approach is used, which includes questions regarding the etiology of the traumatic event (past), the triggers of PTSD symptoms (present), and the installation of future templates related to adequately coping with upsetting events (future).16 Initial phases of EMDR is collecting of history of the client and planning clients treatment, explanation of Professional Med J 2015;22(4): 514-521. 2 the process of EMDR and preparation of client for EMDR. Client is taken through all phases of EMDR in each session. Through the process of EMDR each negative cognition is extracted and substituted with a healthy positive cognition for a traumatic incident. The physical dissonance associated with that traumatic memory are transformed or relieved subsequently. Subjective Units of Disturbance (SUD) is a ten point Likertscale used to measure the level of subjective disturbance and desensitization is attained until the disturbance is substantially reduced. Therapist carries out sets of bilateral stimuli which basically give access to the traumatic memory and its associated emotional burden in the client. Validity of Cognition Scale (VOC) is a seven point Likertscale used to measure the strength of the faulty negative cognition. The process of bilateral stimuli is repeated till the individual consigns a positive thought in place of the older negative thought. The last phases of EMDR are accomplished by positive closure and re-evaluation. The number of sessions essentially depends upon the severity of traumatic event and negative memories. Initially, bilateral eye movements were considered as a key element in the EMDR therapy, however, other external bilateral stimuli have also been used in the EMDR treatment, such as taps (tapping the hands of the therapist)17 and ear tones.18,11 With EMDR unprocessed memories of traumatic experiences, stored in neural networks, become linked with the adaptively processed memories of positive experiences, which are referred to as reprocessing.11 Following a review of seven meta-analyses which explored the effectiveness of EMDR, Spates et al, concluded that EMDR was an effective treatment for PTSD, and equally effective as exposure based therapies, with large effect sizes, and considered EMDR as robust in its overall effect, recommending it as a Level A treatment intervention for adult PTSD.19, 20 Inception of EMDR in Pakistan EMDR in Pakistan owes its inception to a massive tragedy that occurred in October 2005 in the form of an earthquake. An estimated 80,000 people lost thier lives in this natural calamity. There was extensive destruction of assets and property. www.theprofesional.com 515 COPING STRATEGIES DURING CHRONIC ILLNESS Yet soonafter this disaster steered an age of international help and support. One such support was in the form of Humanitarian Assistance Programme (HAP) of United Kingdom. The main contributors to the project being those from the University of Birmingham, Belfast Health & Social Care NHS Trust, Edge Hill University Liverpool and the Centre for Trauma Research & Psychosocial Interventions (CTRPI), Rawalpindi, Pakistan.20 To date more than 180 Pakistani mental health workers have now been fully trained in EMDR including Armed Forces psychiatrists, civilian psychiatrists, clinical psychologists and registered social workers who were predominantly working with earthquake survivors.20 A pertinent question to ask would be as to how would EMDR, as effective evidence based psychological treatment intervention, adapt to being utilized by mental health clinicians in Pakistan?20 This case study aims to investigate the effectiveness of EMDR therapy in myriad of complex psycho-trauma in unique circumstances with an overarching theme contaminated with persistence of terrorism, pressure to perform effectively as a judicial head in a terrorist hit area and failure of response to full trials of SSRIs. The innumerable complex psycho-trauma events included frequent witnessing of brutally tortured headless human torsos, fear of Improvised Explosive Devices (IEDs) enroute to court and his residence, being shot at by the terrorists at his cavalcade multiple times and death of one his close bodyguards. Furthermore distress was caused by constant threatening roar of nearby army artillery guns and helicopters landing in the yard next to his court, pressure from family and friends to quit the job and intention to start afresh in the civil sector all became what was the dilemma that this individual was going through. MATERIALS AND METHOD Subject Single participant of this case study was a sitting session judge of judicial governmental scaffold who reported to this mental health tertiary care facility at his own accord with features of intense Professional Med J 2015;22(4): 514-521. 3 anxiety, depression, maladjustment issues and post- traumatic stress for a duration of 3 months. One of his challenges was to keep a ‘sane mind’ and to give out judicial rulings and judicial orders and by every passing day he felt being compromised at this capacity. The client was initially treated by the one of the authors, a consultant psychiatrist and put on selective serotonin reuptake inhibitor (SSRI) paroxetine with an adequate dose. After undergoing a full trial of SSRI, he remained a partial responder and his symptoms of intense anxiety, terror attacks, being overwhelmingly fearful, depressed mood, low self-esteem and harbouring inappropriate feelings of guilt. Then there were flashbacks of numerous critical incidence coupled with avoidance, nightmares, hyper-arousal and inability to perform as a judicial head in active war stricken area of northern Pakistan. After a trial of SSRIs had failed the patient was offered an alternate in the form of EMDR therapy considering his lukewarm response and plethora of non-relenting psychiatric symptoms. EMDR was offered only as a substitute treatment after discontinuation of paroxetine (SSRI). Prior to start of EMDR he was scored on Impact of Event Scale (IES) and this was noted as pre EMDR IES score. Safe place was established and reinforced with the client. There were more than 25 traumatic events considered as major target and almost all of them were declared as ‘severe’ in intensity and scored on subjective units of distress (SUDS) as 10+. The patient suffered from multiple psychological traumas of diverse forms and fulfilled diagnostic criteria for PTSD as assessed by the English version of the PTSD module of the Structured Clinical Interview for DSM-IV.21 Symptoms were endorsed and informed consent was obtained. EMDR treatment strictly followed the protocol suggested by Shapiro22 and included all eight phases described in her book. Three authors of the study (M.S.Bilal, M.H.Rana and R.Qayyum) – all classified psychiatrists, carried out the treatment at different times. Duration of each EMDR session was one hour more or less. Treatment settings Centre for Trauma Research and Psychosocial www.theprofesional.com 516 COPING STRATEGIES DURING CHRONIC ILLNESS Intervention (CTRPI) which is a supplementary mental health unit of Armed Forces Institute for Mental Health (AFIMH) Rawalpindi was the treatment venue. CTRPI in essence is a tertiary care mental health facility and is a drainage point for peripheral mental health facilities. This centre was established in collaboration with the Aberdeen Centre for Trauma Research (ACTR) Scotland, in direct response to providing services for any form of psycho-trauma and its treatment. In topographical connotations however this centre is about 230 km away from the workplace of the client. He would travel twice weekly for the EMDR sessions from northern Pakistan to CTRPI, a journey demanding considerable bravery and risk involved. A total of 17 EMDR sessions were undertaken. Instruments 1. Impact of Event Scale (IES)23 Developed by Horowitz et al this is a widely used 15 item self-report questionnaire evaluating experiences of avoidance and intrusion which attempts to reflect the intensity of posttraumatic stress reactions23. 2. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)24 This is a semi-structured interview for making the major DSM-IV Axis I diagnoses.24 The Clinician Version, SCID-CV, is an abridged EMDR Session No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 4 version of the SCID-I-RV, adapted specifically to cover diagnoses most commonly seen in clinical settings.25 3. Subjective Units of Distress (SUDS) This is a scale that integrally incorporated in EMDR protocol ranging from 0-10. Subjectively 0 is considered as the least distressful level and scoring of 10 is considered as most distressful level for the client. RESULT After 17 sessions of EMDR, there was marked improvement in his anxiety and mood symptoms. He gradually improved in his mental wellbeing with each EMDR session. His mood improved from subjectively being depressed to subclinical depression/ euthymic. His symptoms of flashbacks, nightmares, avoidance of his work place and also fear for the daily route to his court reduced significantly and hyper-arousal diminished considerably. His life in social and occupational domains improved. The individual was scored on the two scales with pre and post EMDR evaluations. These results are tabulated below in a table form (Table 1). IES scores were taken regularly as they indicated a stressful or traumatic event within the subjects past seven days and since the subject was part of an ongoing traumatic scenario IES scores were taken before each session. Post EMDR IES Pre EMDR SUDS score score 72 15 12 69 12 10 67 11 11 71 13 10 66 9 9 68 7 9 65 9 9 69 14 8 64 7 9 66 8 8 63 9 7 58 6 8 57 7 8 62 11 7 52 7 8 47 6 9 36 13 7 Table-I. The pre and post IES and SUDS score of the patient Pre EMDR IES score Professional Med J 2015;22(4): 514-521. www.theprofesional.com Post EMDR SUDS score 2 1 2 1 1 1 1 1 2 1 0 0 0 0 0 1 0 517 COPING STRATEGIES DURING CHRONIC ILLNESS DISCUSSION This case serves to give a preview of the efficacy of EMDR beyond complex PTSD in an individual with multiple complex psychological traumas and suffering with a plethora of anxiety and affective symptoms. His failure to respond to a completed trial of SSRI paroxetine further gave impetus to the debate of pharmacological versus non pharmacological interventions. Where pharmacological means seemed deficient, this synclactic therapy brought marked improvement in an enduring onslaught of mental horrors for this patient. This individual was not occupationally performing adequately as a judge. If his mental condition had persisted for more time the full aspects of his disorder would have had surfaced. This would have complicated the situation even further by bringing doubt to the court orders passed recently by him. So burden of time to get healthier rapidly was also part of the expected resolution. With the continuing sessions of EMDR more and more traumas were un-repressed and targeted with EMDR. The high pre EMDR scores improved tremendously and SUDS for various events/ targets dropped from 11 or 12 (on a scale of 10) to 1 or 2. The total EMDR sessions undertaken were 17. Where drug treatment had failed for this patient, EMDR brought him back to working levels of occupational effectiveness. After several EMDR sessions he managed to continue with the same line of work in the same terrorist hit war zones not contemplating leaving the profession anymore. Prior to EMDR, his social and family life had almost come to being nonexistent and with EMDR he reported a significant boost in his self-esteem, lifting of mood, enhanced levels of mental wellbeing, feelings of being adjusted within the same harsh circumstances, significant reduction of night mares, reduced levels of hyperarousal even with ongoing complex war against terror. He had become an improved person in terms of personal wellbeing. The clinical efficacy of EMDR in post-traumatic stress disorder treatment for adults has been well established.26 Efficacy of EMDR’s to treat trauma has been demonstrated in approximately 20 controlled studies, in which EMDR was compared to psychopharmacology and various forms of Professional Med J 2015;22(4): 514-521. 5 psychotherapy, on the basis of which the practice guideline of the American Psychiatric Association and the Department of Veterans Affairs and Department of Defense classified EMDR as an effective treatment for PTSD.27,28 The same status is also reflected in numerous international guidelines.29,30,31,32 The efficacy of EMDR for adults with PTSD symptoms has been demonstrated in several meta-analyses33, 34, 35 but incremental efficacy, which means that a new treatment should add incremental value to established treatments, has not yet been supported.36 EMDR, although a well-established and well researched therapy still faces criticism and doubt as to its efficacy and effectiveness. Our study adds impetus to this incremental value of using EMDR as first line treatment in Pakistan as well, instead of just docking at pharmacological interventions. EMDR is now being adapted as first line treatment for PTSD at par with trauma focused cognitive behavioural therapy (TF-CBT) by National Institute for Clinical Excellence (NICE).37 One of the arguments to support why EMDR and cognitive behavioural therapy are effective is that they both share the same neurobiological objective and that is to down regulate the amygdala so as to allow the hippocampus and medial pre-frontal cortex to come back on line.20 EMDR efficacy has been debated for several reasons, but mainly with reference to the absence of an empirically validated model proficiently explaining the effects of the EMDR method38,39 and the role of the considered working mechanism in the form of the bilateral stimuli.40 It has been demonstrated nevertheless that eye movements contribute to less vivid and unpleasant memories in people with non-clinical symptoms.41,42,43 Besides, it has been found that eye movements decrease psycho-physiological arousal and increase parasympathetic activity in people with PTSD symptoms.44,45 Several hypotheses that exist try to explain the mechanism of bilateral stimulation and the mechanism of the processing itself as posited with the AIP model.11,22,16,15 These hypotheses pertain to the EMDR inducing a REM sleep statelike condition,46 the working memory account,38 www.theprofesional.com 518 COPING STRATEGIES DURING CHRONIC ILLNESS the investigatory reflex account,42,47 the increased hemispheric communication account,48 or the hypothesis of relaxation.11 The case presented in this paper had multiple trauma forms and failed drug treatment and yet it was observed that EMDR provided marked improvement in all the domains of his deficits and this was at a prompt speed as compared to cognitive behavioural therapy (CBT) which usually takes longer duration of therapy and more sessions. The improvements in this individual were not short lived indicating permanent changes happening at neurobiological levels of brain. The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: A systematic review. American Journal of Preventative Medicine, 35(3), 287– 313. 6. Saunders B, Berliner L, Hanson R. (2004). Child Physical and Sexual Abuse: Guidelines for Treatment (revised report 4/26/04). Charleston, SC: National Crime Victims Research &Treatment Center. http:// www.musc.edu/cvc/guide1.htm 7. Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually abused children: One-year followup of a randomized controlled trial. Child Abuse & Neglect, 29(2), 143–153. In Pakistan, EMDR is still in its infancy and it’s a novel treatment modality for mental health professionals, psychiatrists and psychologists alike. 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